Questions in the CAHPS® Item Set for People With Mobility Impairments

Topic	Item Number	Question Wording	Response Scale
Visit to doctor	IM1	In the last 12 months, did you visit your personal doctor for care?	Yes No
Being examined on the examination table	IM2	When you visited your personal doctor’s office in the last 12 months, how often were you examined on the examination table?	Never Sometimes Usually Always
Getting weighed at the doctor’s office	IM3	When you visited your personal doctor's office in the last 12 months, how often did someone weigh you?	Never Sometimes Usually Always
Difficulty moving around the restroom	IM4	When you visited your personal doctor's office in the last 12 months, did you try to use the restroom?	Yes No
Difficulty moving around the restroom	IM5	In the last 12 months, how often was it easy to move around the restroom at your personal doctor’s office?	Never Sometimes Usually Always
Pain	IM6	In the last 12 months, did you and your personal doctor talk about pain?	Yes No
	IM7	In the last 12 months, how often did pain limit your ability to do the things you needed to do?	Never Sometimes Usually Always
	IM8	In the last 12 months, do you think that your personal doctor understood the impact that pain has on your life?	Yes No
Fatigue	IM9	In the last 12 months, how often did fatigue limit your ability to do the things you needed to do?	Never Sometimes Usually Always
Fatigue	IM10	In the last 12 months, do you think that your personal doctor understood the impact that fatigue has on your life?	Yes No
Getting physical and occupational therapy	IM11	In the last 12 months, did you need physical or occupational therapy?	Yes No
Getting physical and occupational therapy	IM12	In the last 12 months, how often was it easy to get this kind of therapy through your health plan?	Never Sometimes Usually Always
Getting speech therapy	IM13	In the last 12 months, did you need speech therapy?	Yes No
Getting speech therapy	IM14	In the last 12 months, how often was it easy to get speech therapy through your health plan?	Never Sometimes Usually Always
Using mobility equipment (Identifier)	IM15	Mobility equipment includes things like a wheelchair, scooter, walker or cane. In the last 12 months, have you used any mobility equipment to move around your home or community?	Yes No
Getting mobility equipment repaired	IM16	In the last 12 months, did you try to get your mobility equipment repaired through your health plan?	Yes No
Getting mobility equipment repaired	IM17	In the last 12 months, how often was it easy to get your mobility equipment repaired through your health plan?	Never Sometimes Usually Always
Getting or replacing mobility equipment	IM18	In the last 12 months, did you try to get or replace any mobility equipment through your health plan?	Yes No
Getting or replacing mobility equipment	IM19	In the last 12 months, how often was it easy to get or replace the mobility equipment that you needed through your health plan?	Never Sometimes Usually Always
Ability to walk and/or difficulty in walking a quarter mile (Identifiers)	IM20	A quarter mile is about 5 city blocks or 0.4 kilometers. In the last 12 months, were you able to walk that far?	Yes No
	IM21	In the last 12 months, did you have difficulty or need assistance to walk that far?	Yes No

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Questions in the CAHPS® Item Set for People With Mobility Impairments